# Review the repeated heart-failure transitions and determine the strongest case-management response before the next discharge.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=547044&lang=en  
> language: en  
> subject: Case Management  
> category: MOC

## Question

Review the repeated heart-failure transitions and determine the strongest case-management response before the next discharge.

| Time | Data |
| --- | --- |
| First discharge | Client received written heart-failure instructions but had no home scale and could not identify whom to call for increasing dyspnea. |
| Readmission 18 days later | Client could not afford two prescriptions and missed follow-up because the available bus route did not reach the clinic. |
| Second readmission 24 days later | Client reports limited food choices, difficulty reading the medication calendar, and no home-health contact after discharge. |

Q1. How should the team interpret this trend?

The client simply refuses all care
More printed pages will solve the problem
Each admission is unrelated
Repeated transition failures are driven by unresolved access, equipment, and understanding barriers

Q2. Which response is the priority before the next discharge?

Build a patient-centered plan with pharmacy, social work, transport, nutrition, home health, and follow-up coordination
Repeat the same instructions more loudly
Schedule discharge before assessing resources
Ask the client to solve every barrier independently

Q3. Which finding best demonstrates readiness for discharge?

A discharge form contains a signature
All referrals were entered into the electronic record
The client uses teach-back and medications, scale, transport, appointments, and contact pathways are confirmed
The client promises not to return to the hospital

## Explanation

The pattern reflects unresolved transition barriers rather than a single education failure. Safe discharge planning begins early and incorporates the client's goals, preferences, caregiver availability, functional ability, medication access, transportation, food resources, equipment, and follow-up. The nurse should coordinate pharmacy, social work, nutrition, primary care, home health, and payer or community resources, then use teach-back and closed-loop confirmation that medications, appointments, transportation, a scale, and escalation contacts are actually available. A pamphlet or repeated instruction without solving access barriers does not create an executable plan.

## In-depth explanation

Correct Answer
The client needs a coordinated, patient-centered transition plan that resolves identified social and logistical barriers before discharge.

Why It Fits
Each readmission follows a different unresolved barrier involving medicines, transportation, equipment, food, or understanding.

Clinical Picture
Calling the behavior nonadherence hides correctable system and access failures that case management should address.

Memory Link
A discharge plan is not complete until the client can carry it out.

NCLEX Rule
Involve the client and support people, identify transition risks, coordinate required services, and confirm that follow-up resources are operational.

Why the Alternatives Fail
Repeating generic teaching, scheduling without transportation, or waiting until discharge day leaves the causal barriers unchanged.

Sources
1CMS Condition of Participation - Discharge Planning
2AHRQ Re-Engineered Discharge Toolkit
3NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Medical unit
An older adult with heart failure lives alone and has had repeated short-interval admissions. The case manager reviews what happened after each transition rather than labeling the client as nonadherent.

## Key concepts

- **Case management** — Coordinated assessment and organization of services needed to meet a client's health and transition goals.
- **Care transition** — Movement between care settings that requires accurate information, accessible services, and clear accountability.
- **Closed-loop confirmation** — Verification that a communicated plan was received, understood, and completed or assigned to an accountable person.

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